Provider Demographics
NPI:1598271819
Name:EBRAHIMI, SHIRLEY
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:
Last Name:EBRAHIMI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5913 SATURN ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-3913
Mailing Address - Country:US
Mailing Address - Phone:323-719-1267
Mailing Address - Fax:
Practice Address - Street 1:9171 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90210-5530
Practice Address - Country:US
Practice Address - Phone:310-385-9128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-22
Last Update Date:2021-07-07
Deactivation Date:2018-08-01
Deactivation Code:
Reactivation Date:2021-07-07
Provider Licenses
StateLicense IDTaxonomies
CA62831183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist